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SAN Jq&QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGR(WD STORAGE TANK PROGRAM WE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> -Ips <br /> FACILITY DRESS SITE PHONE#WITH AREA CODE <br /> Z-/ 19 <br /> 4 Z CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANTSONTACT NAME <br /> c/SSIrqE77 --.r <br /> TK ld-mc-- / T1 <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> -/ Z2/2 40- ad) 9-3-1 /z/re7 <br /> CITY I STATE t ZIP CODE CIRCLE WORK TO BE DONE: <br /> 4F5:�) yt2 —Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1997-1999 2000 2001 2002 <br /> $500 FEE INCLUDES FACILITY FEE+I TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$10/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place) <br /> TANK ID#(s): CLOSURE FEE=$267/TANK I #TANKS X$267 <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$2671 FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) $ <br /> TANK ID#(s): PLAN CHECK FEE $712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267 <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY <br /> PIPING REPAIR FEE $267/FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE $20 <br /> CONSULTATION FEE $891 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89 HOUR <br /> SAMPLING INSPECTION FEE $89/HOUR <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED CHECK 1; RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 3115f02) <br />